The long-term goal of this research is to improve the quality of care provided to VA Community Living Center (CLC) residents with limited life expectancy (LLE) and/or advanced dementia (AD), through the safe and effective use of medication that is aligned with their goals of care. In the years leading up to the development of AD and other life-limiting conditions, most CLC residents have accumulated multiple chronic conditions requiring medication therapy (e.g., coronary artery disease, hypertension, diabetes). However, practice guidelines developed for general adult populations calling for intense treatment of these conditions may no longer be appropriate for residents with LLE/AD, given reduced potential to live long enough to experience benefits and higher propensity for adverse drug reactions. Several geriatric groups have issued recommendations for intense chronic disease treatments to avoid in patients with LLE/AD, but these recommendations have not been consistently integrated into VA or other disease-specific guidelines and their adoption in CLC practice is unknown. These LLE/AD-specific recommendations are also largely based on expert consensus about hypothesized risks and benefits, rather than direct evidence about actual risks and benefits from rigorously designed studies with LLE/AD patients. The lack of direct and specific evidence about this risk/benefit balance hinders the ability of Veterans, their informal caregivers, and VA providers to make informed, shared decisions that are aligned with Veterans' goals of care. In partnership with the VA Office of Geriatric and Extended Care Services (GEC), VA PROMISE Center (Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-Life), VA Pharmacy Benefits Management (PBM), and CLC clinicians, we propose a mixed-methods study to understand variation in and outcomes of intense vs. de-intensified treatment in Veterans admitted to a CLC and develop an intervention toolkit to serve as the basis for quality improvement (QI) efforts. Specific aims are to (1) describe patterns of receipt of intense vs. de-intensified treatment for lipid, blood pressure (BP), and glycemic control in Veterans with LLE/AD after CLC admission; (2) examine effects of intense treatment for lipid, BP, and glycemic control after CLC admission on all-cause negative events and disease-specific hospitalizations and emergency visits in Veterans with LLE/AD; and (3) using semi-structured interviews with providers and family caregivers and an established intervention mapping framework, identify key barriers and facilitators to implementing LLE/AD-specific recommendations and design an intervention toolkit to serve as the basis for QI efforts. For quantitative aims 1-2, we will link Minimum Dataset (MDS) assessments, PBM medication records, VA utilization/clinical data, and Medicare claims to examine variation across CLCs in intense vs. de-intensified treatment; identify patient, caregiver, provider, and facility factors contributing to this variation; and determine effects on all-cause and disease-specific negative events. Our analytic approach involves propensity score methods with inverse probability of treatment weights to address potential selection bias and confounding. Using results from Aim 1 to purposively sample from CLCs with lower proportions of intensely treated residents (early adopters of LLE/AD recommendations) and higher proportions of intensely treated residents (late adopters), qualitative Aim 3 will involve semi-structured interviews with providers and family caregivers of recently deceased CLC residents. With input from our partners, we will use these data to map key barriers and facilitators to implementing LLE/AD-specific recommendations and develop an intervention toolkit that will serve as a basis for QI efforts. This study addresses the HSR&D Priority Area on Long-Term Care and Caregiving and Strategies 1-3 of the VA Blueprint for Excellence. It will have significant impact by providing VA with critical information and tools needed to optimize QI efforts to facilitate implementation of LLE/AD-specific treatment recommendations and support improved shared decision-making about medications in CLC residents near end-of-life.